Anti-wrinkle injections

(The TGA does not allow doctors to advertise or even mention this product by name on a website.  Yes I know lots of other doctors get away with it, but they don’t have competitors dobbing them in like I do)“Anti-Wrinkle Injection Stuff From Allergan (“AWISFA”)” 

You can barely open a popular magazine today without finding some article about “AWISFA”.  Which movie star has it. Which needs it. Who is having too much. Over 40 with smooth skin? They must be using AWISFA. An odd expression, or indeed lack of expression? Proof of the effects of AWISFA.


Well, here at Peach we do about a dozen AWISFA treatments every day. Add it up: that’s a lot of experience over 10 years. Anyone can tell you the basics of AWISFA use. Googling it today (20/02/12) gives 41,500,000 hits, and a fair slice of these will be clinics breathlessly inviting you to come into the parlour of everlasting youth with AWISFA.


So here are a few things you might not know.


1) AWISFA relaxes muscles, relaxes muscles, relaxes muscles. IT HAS NO DIRECT ACTION ON SKIN.



muscle treatment


Let’s say we treat your frown lines: the vertical lines between your eyebrows. What happens is that in around 3 days, typically, after a treatment the injected muscle stops working, and you will find you can barely frown any more. You will look less angry. You will look content, non-plussed, calm and amicable. But your wrinkles will not be gone.


Skin structure can’t change in only three days. The epidermis, for starters, renews itself every 30 days on average. So clearly any epidermal problem takes 30 days to wash through even if immediately corrected 100%.


The structure of a wrinkle, however, is in the dermis, just under the epidermis, and the dermis is mostly collagen. Collagen takes months to be renewed.


So, AWISFA keeps your skin still, and whilst your skin is being kept still it slowly changes itself from wrinkled to flat.


2) AWISFA is the most expensive commercially-produced substance on the planet


If you have a 10-unit treatment of AWISFA at Peach you will pay $195.


This is a good price. Not the absolute cheapest you will find, but at the cheaper end of the spectrum, and most people aren’t silly enough to entrust their face to a doctor or nurse who can do no more than offer a bargain-basement absolute lowest price in order to find patients.


Now, that 10 units represents just 0.43 nanograms of pure AWISFA.


A nanogram is a billionth of a gram


So if you are paying $195 for 0.43ng, that’s equivalent to $453 per nanogram, or $453,000,000,000 per gram.


Today, gold is $51.74 per gram.


Therefore, Agent B is 9 billion times more expensive than gold.


3) Totally freezing your face with AWISFA is unnecessary if your goal is to reduce lines.


Whilst the exact outcome of AWISFA treatment cannot be perfectly guaranteed each time, I like to reduce movement at a treatment area with AWISFA by around 80-90% rather than 100%.




Well, it’s a more natural look, for starters.


There’s less chance of a side effect.


It’s less expensive.


If it is not enough, I can always put in more, but if I put in too much, I can’t take it out.


Results are better if we put in smaller doses more often rather than larger doses less often (assuming the same total dose per year)


But finally, it is not only the extent of your movement that causes lines, but also the frequency of movement.  And when AWISFA reduces your full range of movement, under maximum conscious effort, by 90%, it also reduces frequency of movement by 90% because all your half-hearted, distracted, subconscious movements simply no longer occur at all.


So if reducing the range of movement by 90% means that we also reduce the frequency of movement by 90%, then we have reduced the total amount of movement in any given day by 99%.


And that’s enough.


4) Where do we use  ”AWISFA”?


a) Glabella lines:


The glabella is that 10c-piece-sized area of skin between your eyebrows and above the top of your nose.  The term derives from the Latin glabellus, which means smooth and/or hairless. But sometimes it is not smooth, for here reside the commonest lines we ever treat with AWISFA: frown lines.



Some patients with thick skin will have just one deep line. Others with very thin skin may have four or six lines. But most will have two of these vertical lines between their eyebrows making them look perturbed and angry.

Somewhere between 8 and 20 units of AWISFA will induce relaxation in the offending muscles within a few days , and from then on the lines improve and improve as the skin stays still.

One common error that occurs in treating the glabella is the error of injecting the lines instead of the causative muscles. Patients often assume that the AWISFA has to be placed into the wrinkles themselves but that is wrong.

Another error is to think that a filler would be first choice. Wrong. For if a filler is placed here without there being any control over the movement then the continuing movement will either push the filler out of the line or create a new line parallel to the filled one. So with some thought and experience it can be understood that stopping the causative movement is fundamental to getting on top of this particular line.

My youngest glabella patient was just 19. Whoa! don’t get so mad at me. This 19 year old lass with otherwise wonderful skin and impeccable features had a single line down her glabella you could roll a coin in. She clearly had spent most of her life either scowling or puzzling or doubting or disputing.  AWISFA fixed the line and she was very grateful.

One more benefit of treatment. One thing we invariably do is subconsciously react and respond to the perceived moods of those around us. So if someone in our midst looks angry, we tense up. They, in turn, detect out tension, and often themselves tense up in response. You can see how this would create a vicious circle.

AWISFA treatment to the glabella can turn a vicious circle into a virtuous circle. For if we make you look more relaxed, then others will relax more in your presence. You in turn will subconsciously detect the cues of their relaxation, and will become more relaxed in response.

One treatment and everyone’s happy.


b) Forehead lines


Forehead lines are those horizontal lines above your eyebrows and below your hairline. They are sometimes called “surprise lines” and are easy to reduce with AWISFA.



Prior to jumping in with the needle, though, it is important to watch the brows rise and fall a few times in order to infer the exact location and extent of the frontalis muscle. This is a variable muscle that creates different patterns of movement in different individuals. Obviously, the pattern of treatment has to be designed to match the pattern of movement. Errors will create an odd effect, like the ‘Puck’ effect for example in which the treatment has not reached laterally to the edge of frontalis, creating a look reminiscent of Shakespeare’s “Puck” in  A Midsummer Night’s Dream. 

The other point in treating frontalis is to be aware that over treatment in some will lead to an unwelcome drop in eyebrow position. Patients with high-sitting brows will not be bothered so much by this, but those with brows that sit quite low, or those developing suprapalpebral hoods, will not be grateful if the treatment for which they have paid leads to brows and hoods sitting uncomfortably low. In such an instance the dose employed has to be conservative, allowing enough persisting movement for a comfortable brow position to result.


c) Crows feet


These lines radiate from the outer corner of your eye. In most, AWISFA will significantly soften these lines.



Who remembers Steve Martin? Great comedian. “The Jerk”. “Roxanne”.

Who remembers the way his eyes almost totally close when he smiles?

Classic candidate for “AWISFA” to the crows feet.

For AWISFA will also help open up the outer aspect of the eye.

But it is important to understand AWISFA alone cannot eliminate all crows feet lines in the same way it might eliminate all glabellar lines. This is because the orbicularis oculi muscle into which it is injected is not the only muscle responsible for crows feet development.

The other muscle responsible is zygomaticus. This is the muscle with which we smile. It’s the muscle that raises the corner of the mouth with each smile, thus pushing soft tissue up toward the immobile orbit, thus leading to a folding of the skin beneath the orbit, and thus causing indirectly lower crows feet.

The only way to eliminate crows feet with AWISFA would be to immobilise both orbicular is oculi AND zxygomaticus, in which case we wouldn’t be able to smile at all. Bad idea.

We therefore seek to soften crows feet lines with AWISFA, whilst accepting we won’t entirely eliminate them.


d) Bunny/nasalis lines


The three classic sites for this treatment are the glabella, the forehead and the crows feet.


Patients will often have these three sites treated, often expertly and well, but will appear as obvious AWISFA patients due to the persistence of bunny lines.



This lass can’t frown, and probably can’t raise her eyebrows or activate her crows feet, but those “bunny lines” on her nose are still very active. Anyone with stand-alone bunny lines has probably had AWISFA elsewhere on the face.


Treating these with AWISFA usually requires only 2 units each side into the nasalis muscle,  although sometimes another 2 units needs to go into each levator labii superioris alaque nasi muscle.


e) Lower eyelid pretarsal orbicularis hypertrophy


See the bulge of this lass’s lower eyelid in the photo on the left?

See that it is gone in the photo on the right?


2 units of AWISFA did that.


f) Brow lift


One of the things commonly misunderstood about AWISFA is that it is said to make skin tighter and thus cause lifting.


Well, it doesn’t. Not really.


AWISFA relaxes muscles relaxes muscles relaxes muscles.


BUT BUT BUT if we strategically place AWISFA into the right muscles and at the right dose, we can trick the unaffected muscles into causing a brow lift.




It happens in neurology that if two or more muscles act together to produce a certain action, and one such muscle is damaged or diseased, the other muscle(s) will act stronger to compensate. This is called “recruitment”.


For example, three muscles act together to flex your elbow: biceps, brachialis and brachioradialis. If brachialis is cut, biceps and brachioradialis will get thicker and stronger to compensate.


Now, in order to get the brows to rise, we need to trick the lateral (side) parts of frontalis to pull harder.  We do this by applying some AWISFA to the *central* section of frontalis. This prompts the lateral parts of frontalis to pull harder to try to compensate for this perceived weakness, and this pulls up the brows in the process.


Neat? Yes.


The other thing we do to prompt a brow lift is to place a little AWISFA into the orbicularis oculi muscle just under the brow. Orbicularis oculi at this position would ordinarily pull down the brow a bit as it contributes to closing the eyelid – by diminishing this activity there is less total pull-down on the brow, so the pull-up of frontalis can occur against less opposition.


The net effect of these two manouvres is to produce a modest but welcome browlift in most patients.


g) Gummy smile


Some people find that when they smile their top lip rises so high that a sizable acreage of bright pink gum comes on display, and they don’t like it.



This is called a gummy smile, and in this case you can see that the upper lip is being pulled high laterally.


Careful placements of a few units of AWISFA into the levator labii muscles will reduce this excessive muscle pull, leaving less gum exposure in smiling.


h) Deep nasolabial lines



Nasolabial lines run from the edge of the nostril down to the corner of the mouth, and *everyone* has these lines when they smile: even my kids display nasolabial lines on smiling. But as we age they commonly get deeper and persist even when we are not smiling – in this case a dermal filler is the lost useful initial strategy. However, some patients manifest very deep nasolabial lines due to overactivity of levator labii superioris alaque nasi. A little AWISFA, again, will reduce this problem.


i) Smoker’s lines


This is something of a misnomer. Cigarettes per se do not cause these lines, and many non-smokers still have them.



Rather, it is the act of pursing one’s lips that causes these lines to appear. Horizontal action of orbicularis oris along the white upper lip, repeated frequently, causes these creases to form.


Interestingly they almost never occur in men. Due to the presence of full moustache follicles, it’s hard for a man to purse his upper lip the way a woman can.


And mumblers, with poor diction, don’t tend to get them (unless they smoke); only those with expressive mouths and accurate diction tend to get these lines as they wrap their expressive lips around every syllable they utter.


j) Sad mouth


This girl is pulling down the corners of her mouth with a bilateral muscle called depressor anguli oris.


If you do this all the time, then a) it looks sad, and b) you’ll get these:



These are also called “marionette” lines or melomental lines. And whilst the commonest and first treatment for these is often a filler, filling is not always the right first thing to do. If there is overactivity of the depressor anguli oris muscle then a little AWISFA will help. It will also help raise the corner of the mouth and give you a little Mona Lisa smile. Nice.


k) Chin crease


Those who manifest overactivity of depressor anguli oris will often over-act mentalis as well, giving rise to a chin crease:



Again, a little AWISFA into the mentalis muscle, usually 2 units each side, will diminish mentalis activity enough to improve this line.


l) Cheek mesotreatment


Small doses of AWISFA can be applied throughout the cheeks, indeed over most of the animated areas of the face, in order to subtly diminish the hyperactivity that leads to disproportionate lining in some patients. So, if you can’t help yourself over-animating your face, and you are developing lines you don’t want as a consequence of this, a little AWISFA may diminish the movement enough to you improvement without interfering with you need to express and do what you need to.


m) Nefertiti lift


Nefertiti was an Egyptian princess with a very sharp jawline according to the images we have of her, and the Nefertiti lift is an AWISFA technique designed to sharpen the jawline by reducing the pull-down effect of platysma specifically along the jawline. Dose varies according to need and according to whatever other AWISFA treatments are being performed but generally 10 units each side brings about the effect we want


n) Masseter hypertrophy/square jaw/masculine jawline.



The jawline on the left has a powerful, even macho look, due to thick and strong masseter (jawline) musculature. Now, this is a look some people may like, as it exudes force and strength and even aggression. Others may prefer the softer look on the right, following AWISFA into the masseters. The latter is less macho, more oval rather than square.


This treatment also helps with bruxism (grinding your teeth) and some cases of TMJ pain.


o) Neck pain


For whatever reason, some people develop focal neck pain inadequately relieved by analgesics physiotherapy and time.


If you have neck pain and can point with one finger to the focal point of your pain, as if to say “the pain is RIGHT HERE”, then there is a good chance a few units of AWISFA to that point will help relieve your pain for up to a few months.


Whether this effect occurs because AWISFA relaxes tight muscles that are contributing to your pain complex, or whether there is some direct action, is not yet known, but, hey, if it works it works.


often when nothing else will.


p) Migraine


As with neck pain, the key here is to be able to say there is a specific trigger point or focal point to the pain. If you have a migraine pain that you feel all over your head, AWISFA is unlikely to help. But if you can point with one finger to the place from which the pain comes, then a jab of AWISFA to that point is definitely worth a try.


q) Horizontal neck lines


Those horizontal lines across your neck are due to overactivity of the platysma muscle acting as a broad sheet



Usually 20 units of AWISFA, spread out over 40 injections of 1/2 unit each over the area of platysma causing the lines, will reduce movement enough to see significant reduction in those lines.


r) Platysmal bands


These arise when certain strands of the platysma muscle flex more than the rest of the platysma.



Injecting 10 units of AWISFA along the line of the platysmal band will relax that band, resulting in a smoother neck.


s) Torticollis


Torticollis is a condition involving long-term painful contraction of the sternomastoid muscle. Such patients thus have a head that is chronically tilted and turned in one direction.


AWISFA injected into the sternomastoid will relax the muscle, reduce pain and allow a more symmetric posture of the head and neck to be attained.


t) Tight trapezius


The trapezius is the major muscle running from the back of the neck to the top of the shoulder. Chronic tension in this muscle can cause pain, and, once more, injections of AWISFA can relieve the tension and reduce the pain. Patients who respond to this treatment are extremely grateful.


u) Axillary (armpit) sweating/hyperhidrosis


Some people unfortunately suffer a degree of underarm sweating that is embarrassing and unsightly. Deodorants and antiperspirants may not help or may not help enough, and historically such persons had no alternative but to consider surgery to reduce their sweating.


Today, such unwanted sweating can be hugely reduced or eliminated by injections of AWISFA.


The major factor inhibiting the wider use of AWISFA for this indication is cost. Textbooks and published articles on the use of AWISFA for underarm sweating have recommended doses of 50-100 units per side, which would render the possible cost of treatment to be over $2000 per three months.


At Peach our experience over the years has been that a very satisfactory reduction in sweating can be achieved with much lower doses, and so we routinely inject 20 units each side. This reduces the cost to $590: not cheap, but manageable. We have found it to be rare that patients need a higher dose than this, and, even if this is the case, we can say that we have at least tried the lower dose to deliver a cost-effective result.


v) Palmar (hand) sweating


Hand sweating can be similarly reduced with injections of AWISFA. but the trick here is of course managing the discomfort of having so many injections into sensitive fingers and palms. Dr Mahony therefore performs nerve blocks to the median and ulnar nerves in order to completely numb the hands for AWISFA injections.


The numbness lasts for an hour or so and during this time you cannot drive a car. Then once the AWISFA kicks in some patients find some of their fine hand function is more difficult.


Obviously this is a treatment that is not entered into lightly, and patients have to be seriously troubled by their hand sweating to contemplate it.


w) Plantar (foot/sole) sweating


Foot sweating can be reduced by injections with AWISFA as well.  Once again, nerve blocks are used to achieve anaesthesia and then the AWISFA is injected in multiple injections covering the sole of the foot. Again, this treatment is really only for the very committed.


Our fees for AWISFA

10 units $195

20 units $345

30 units $470

40 units $590

And $10 per unit thereafter in the one treatment session. (therefore, e.g. 100 units $1190)